A gynecologist explains perimenopause and shares some of the best options for managing symptoms.
In this episode of Health Matters, Dr. Mary Rosser, a gynecologist at NewYork-Presbyterian and Columbia, explains perimenopause, breaking down what symptoms are normal, when it's time to see a doctor, and the best options for managing some of the more challenging symptoms of perimenopause.
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Dr. Mary L. Rosser, M.D., Ph.D., NCMP is the Director of Integrated Women's Health at NewYork-Presbyterian/Columbia University Irving Medical Center and the Richard U. and Ellen J. Levine Assistant Professor of Women's Health (in Obstetrics and Gynecology) at Columbia University Vagelos College of Physicians & Surgeons. She joined the faculty of Obstetrics and Gynecology at Columbia University in April 2018 to provide routine gynecology care and to further develop a comprehensive well-woman program. She has been a practicing obstetrician gynecologist for more than 20 years, starting in private practice and then joining the faculty at Montefiore Medical Center in Bronx, NY. While at Montefiore, she created, launched, and led the forty-person Division of General Obstetrics and Gynecology. Dr. Rosser received her undergraduate degree at Emory University and a Ph.D. in Endocrinology at the Medical College of Georgia. She attended Wake Forest University School of Medicine and completed her residency at Emory University. She is also a NAMS Certified Menopause Practitioner, able to provide high-quality care for patients at menopause and beyond.
Primary care and heart disease in women have always been areas of focus for Dr. Rosser. She conducted basic science research on heart disease during graduate school and was the Chair of the "Women & Heart Disease Physician Education Initiative" for District II of the American College of Obstetrics & Gynecology. She continues to conduct clinical studies around patient awareness and understanding of heart disease and well-woman care. Dr. Rosser serves on the Medical Leadership Team of the Go Red for Women movement of the American Heart Association and she is ACOG's liaison to the American College of Cardiology.
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Dr. Mary Rosser: Everybody's perimenopause is unique, you may not have the same set of symptoms that your best friend has. If you're experiencing symptoms that are not right for you or you feel off, it's important to see your healthcare provider because a lot of the perimenopause symptoms can mimic other conditions including thyroid conditions, anemia, depression, anxiety, aging in general. And so it's important to get evaluated, to make sure there's nothing else going on.
Courtney: Welcome to Health Matters – your weekly dose of the latest in health and wellness from NewYork-Presbyterian. I’m Courtney Allison.
Menopause has been having a moment and there's no shortage of advice on how to navigate this big change. But what about perimenopause? For many women this time leading up to menopause can feel uncertain with the range of confusing symptoms.
That's why today we're talking to Dr. Mary Rosser, a gynecologist at New York Presbyterian and Columbia, who helps guide women through this transitional time. Dr. Rosser demystifies perimenopause, breaking down what's happening in the body, how to know if you're going through it, and ways to manage its challenges.
Courtney: Dr. Rosser, thank you so much for joining us today.
Dr. Mary Rosser: Thank you. It's so nice to be here.
Courtney: So today we're here to talk about perimenopause. Can you tell us, what is perimenopause?
Dr. Mary Rosser: So it's a great question. We do know that there is a period of time leading up to menopause. And menopause, just to first define that, is the absence of a menstrual period for 12 consecutive months. So that marks menopause.
The time before that, sometimes it's very chaotic. And you really don't know what's going on. And since it hasn't had much attention, people just start getting symptoms and they have not been provided, a lot of times, with information about these symptoms. The average age of menopause in the US is 51 to 52. The average age of perimenopause is about 46, 47. However, people can get symptoms earlier and it just marks the fluctuation in hormones that starts to occur. And you will see that reflected in the menstrual cycle.
Courtney: And how long does perimenopause typically last?
Dr. Mary Rosser: So we tell people about four to ten years and some people it's gonna be less time, some people maybe a little bit more time, but on average it's about four to ten years.
Courtney: Okay, so could we get like a quick high level health class? What is happening in our bodies during perimenopause?
Dr. Mary Rosser: So, as women, we're born with a certain number of eggs, right? And then starting at puberty, when we start our periods, those eggs develop and they are released. When you're in your, about your mid thirties. Those numbers of eggs start to drop off very quickly.
It's very quick after 35. There's a drop off between 37 and 39, and then 40 to 42 more of a quick drop off as well. So if your number of eggs is dwindling, you're therefore not making estrogen like you were through your mid thirties.
And so your estrogen levels are starting to drop, and that's made by your ovaries. And so as your estrogen levels start to drop, you start having these symptoms, your irregular bleeding, the symptoms of menopause we talked about. So with the hormone fluctuations, then you're getting fluctuations of periods and symptoms, and so that's what we're trying to minimize or mitigate. We're trying to even it out so that you feel better.
Courtney: Are there any ethnic or racial differences in how women experience perimenopause?
Dr. Mary Rosser: There are, and it's really very, very important just in like all areas of medicine and life that we look at menopause and perimenopause through the lens of racial and ethnic sensitivity. For example, African American women have longer perimenopause periods and more intense. They have hot flashes, night sweats earlier. They're more intense, many times, and they last longer. So we do need to pay attention to that. I tell residents and medical students, we have to be culturally sensitive at all times and really listen to people and not dismiss their symptoms.
Courtney: So I think you mentioned earlier that sometimes people start to get symptoms and don't even really know what's going on. So what are some of the most common symptoms of perimenopause?
Dr. Mary Rosser: So the first thing I tell women is your cycle will change. So that usually is the first thing that happens. Though, this can be variable, like everything in life, right? And some women get very lucky and if they have regular cycles that they can predict every 28 or 30 days, they can become shorter. So the interval may go to 21 to 24 days.
It may be lighter, it may be heavier. Or the interval can be longer. So it's any change. And it's not just one cycle, it would be multiple cycles, but it can be variable. Then you can start having some of the more classic or hallmark symptoms like hot flashes and night sweats. They're called the vasomotor symptoms. This, it can start a cycle, which would be insomnia or inability to fall asleep, but more commonly waking after the onset of sleep, and not being able to go back to sleep.
Then this cycle continues through the next day. Right? And your energy is low, fatigued. You may feel mood irritability. Some people say to me, I feel like I'm in a rage. And you're really exhausted. So that is the cycle. When we're talking about treatment, we're talking about breaking that cycle.
People start complaining of brain fog, the inability to concentrate. They may become forgetful, they may have joint pains. Low libido, vaginal dryness, vaginal concerns. So the list continues and there's about 40 possible symptoms that people can have during perimenopause.
And everybody's perimenopause is unique, so you may not have the same set of symptoms that your best friend has. If you're experiencing symptoms that are not right for you or you feel off, some people have depression and anxiety during this time, or it's exacerbated. But it's important to see your healthcare provider because a lot of the menopause symptoms, perimenopause symptoms, can mimic other conditions including thyroid conditions, anemia, depression, anxiety, aging in general. And so it's important to get evaluated, to make sure there's nothing else going on.
Courtney: Well, my next question was gonna be, are there any symptoms that are not normal or that people potentially going through perimenopause should watch out for, but listening to you speak, it sounds like all these symptoms could be other things, so you might wanna talk to your doctor regardless.
Dr. Mary Rosser: Right. And you know, I do tell women, “write down your symptoms” because we can look over a period of several months and see what are the most disturbing symptoms for you, and how can we enhance your quality of life by reducing those symptoms.
Courtney: So all these symptoms sound like so much fun. Well it's even thinking, just the one waking up right after you fall asleep, that just sounds terrible. 'Cause everything seems harder in the middle of the night anyway. So that's just one of many that sounds really tough to go through.
Dr. Mary Rosser: Well, and that's why we have found through great research that the number one treatment for that is cognitive behavioral therapy. Because what usually does happen is that people wake up, they can't go back to sleep, they're restless. They start thinking about their day that has passed, the day coming up, all the issues that are going on, whether it's with their children, aging parents, you know, their relationships, the outside world.
And so it's hard, really, to let your mind release so you can fall back to sleep. I tell women, don't stay in bed and just be restless. Get up. Go find a great book, without the screen, and sit in a chair with soft light. And then hopefully you'll feel like you need to fall back asleep.
Courtney: That’s beautiful. I love how you painted that with some soft light, a chair. That actually sounds quite cozy.
Dr. Mary Rosser: Yeah. At least you'll be comfortable and you won't be thinking about your list.
Courtney: Yes, exactly, the list. So cognitive behavioral therapy is one option. Are there any other ways listeners can help mitigate or offset some of the symptoms on their own?
Dr. Mary Rosser: Yeah. So, you know, there are four big buckets of possible treatments, but the first one that I really talk to everyone about is lifestyle. And it's not just getting your diet in order. It's really about being healthful when you are eating, making healthy food choices, minimizing or even eliminating alcohol and get moving every day.
And this doesn't mean that you have to go to the high intensity training classes. Those are all wonderful, but if you don't have the time, it's small, bite-sized, manageable times that you can do some exercise. So we wanna get the cardiovascular exercise in, even if it's 15 or 20 minutes.
You can also do acupuncture. That works very well for menopause symptoms, including the lack of sleep associated with menopause. Yoga, tai chi, meditation, breath work, all of these things work very well.
Courtney: I think I've heard that a lot of women complain about weight gain during perimenopause. How do you typically approach that conversation with your patients?
Dr. Mary Rosser: Anticipatory guidance is something that I try to do in my practice. I start talking to women in their late thirties, definitely by their early forties about changes they might see happening so that they're not frightened, because that's what happens is you, you're afraid because you've never noticed this before.
And the weight is one where people have, you know, they're stable at a certain weight and they all of a sudden notice that they put on weight that they can't get rid of, and that weight goes to the belly and to the thighs. And it's very hard to get rid of it. It's not right to simply say to a woman, oh, just eat less and work out more.
Because the weight shift, and that's what it is with menopause, is more of a metabolic issue. And, so, you know, it's helpful to change the way in which you're eating, to look critically at how you're eating, how much you're eating. Even seeing a nutritionist or a dietician is great. And it's important to look at your exercise regimen and making sure you have weight training in there. But there is no magic bullet and I think sometimes it's very challenging for women.
Courtney: So that takes us to, what treatments do you recommend for women who may be struggling with severe perimenopause symptoms?
Dr. Mary Rosser: Yeah, so again, you see your provider. You can talk about hormone therapy, which we love. And really what we're doing is we're adding back a small amount of what you were making that you're not making, so that we're kind of evening out the scale there. We also have non-hormonal possibilities, and this is for people who simply can't take hormones if they've had breast cancer, if they've had, you know, blood clots, certain situations of blood clots, stroke, or heart attack, other estrogen dependent cancers, they can't take hormones.
Or women who simply just don't want to take hormones. So we can do the hormone treatments, we can do the non-hormone treatments, such as anti-anxiety or antidepressant medication, which actually decreases hot flashes and night sweats, improves sleep, and therefore it will also improve your mood the next day.
But I exhibit great care when I'm talking about this class of drugs because we don't wanna risk women walking out of the office saying, oh, my doctor just said, take this antidepressant. And so you don't want the patient to feel that you're saying, oh, you're just depressed, take this medication because it actually chemically does work to reduce the hot flashes, et cetera.
And then we have a newer class of drugs that actually were developed to act directly in the temperature control center of the brain to reduce or eliminate hot flashes and night sweats. And there's that cycle again. So allowing people to sleep better and improves the mood the next day. So you just want people to feel better as they're going through this transition.
Along the lines of hormone therapy, in perimenopause, a great tool is a low dose birth control pill. That comes as a pill, a patch, or even a ring. And very low doses, if people don't smoke, if they are not hypertensive or have any contraindication, low doses of birth control pills will also help to smooth out the hormones so that you will have birth control, plus you will have symptom management and be able to feel better.
And then we can transition you over to hormone replacement therapy or to some other medication, as you are entering menopause. So those are great tools.
Courtney: So, you know, of course this can be very confusing for people who are unsure if they're entering perimenopause. Do you have any recommendations for how women entering this phase of life can navigate it?
Dr. Mary Rosser: Yeah, so you have to be very careful and make sure that you're looking at evidence-based techniques or evidence-based care models. Menopause.org is a fantastic tool. It is put out by the Menopause Society, which is the society in the US or North America, that sets the guidelines for menopause care and it's all evidence-based.
And then you can jump off from there. You can go to the American College of Obstetrics and Gynecology and read from that place and make a list, so that you have your thoughts together when you talk to your provider.
Courtney: Dr. Rosser, thank you for being so generous with your time and insight. This is amazing.
Dr. Mary Rosser: Oh, so my pleasure and thank you so much for highlighting this and getting the word out. It's really important.
Courtney: Our many thanks to Dr. Mary Rosser. I’m Courtney Allison.
Health Matters is a production of NewYork-Presbyterian.
The views shared on this podcast solely reflect the expertise and experience of our guest. To learn more about Dr. Rosser’s work with patients, check out the show notes!
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